Provider Demographics
NPI:1609227156
Name:KING, VIRGINIA
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1481 WINDSOR DR
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-5416
Mailing Address - Country:US
Mailing Address - Phone:909-361-6470
Mailing Address - Fax:
Practice Address - Street 1:1481 WINDSOR DR
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-5416
Practice Address - Country:US
Practice Address - Phone:909-361-6470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-27
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA112009106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist